1. Technical Field
The present disclosure relates to medical information management, and more particularly to a system and method for billing insurance companies or their pharmacy benefit managers for services performed by medical providers and other non-pharmacy providers for services covered under pharmacy benefits.
2. Related Art
The business processes and management systems for physician offices, medical insurance companies and other entities involved in providing services covered under medical benefits have developed and evolved separately from the business processes and systems for the pharmacy providers, pharmacy insurance companies and pharmacy benefit managers involved with processing claims for services covered under pharmacy benefits. Two completely different sets of business and transaction standards have been formed and have been entrenched in each of the two parts of the healthcare service market. As a result, two completely separate national data transaction processing infrastructures each with their own participants have been created in the country: one for pharmacy services, and the other for medical services. Recently, physician offices and other medical providers such as retail pharmacy clinics have begun to perform services for patients that are covered by the patient's pharmacy insurance coverage such as administering preventative vaccines or dispensing drug products. The dichotomy of claims processing infrastructures make it very difficult or impossible for medical providers to submit claims using their current medical billing systems to pharmacy insurance companies or their pharmacy benefit managers for services covered by pharmacy insurance benefits. This problem has severely inhibited the growth of the practice of medical providers to perform services such as vaccinations, which in addition to the loss of business to the medical providers, also limits access to patients for important medical services.
There are several notable problems that exist as a result of divergent healthcare markets and information processing relating thereto. The first problem is that medical billing systems use transactions standards developed and maintained by ASC (Accredited Standards Committee) X12, for eligibility determination and the submission of claims, whereas pharmacy systems use transaction standards developed and maintained by the National Council for Prescription Drug Programs (NCPDP) for these two purposes. The bifurcation was validated and strengthened by the HIPAA (Health Insurance Portability and Accountability Act) regulations, which mandate the use of the two separate standards in the two environments. This makes it impossible for a medical billing system to transmit a claim directly to a pharmacy insurance company or their pharmacy benefit manager. A further problem is that medical billing systems are developed assuming batch processing of claim transactions, whereas pharmacy insurance company claims processing systems are developed assuming real-time processing of claim transactions.
Billing systems used by medical service providers such as physicians gather data regarding services to patients over a period of time and then create a batch of claims transactions for these services. These batches are then transmitted as a file to a medical claim clearinghouse entity using a file transfer protocol. The medical claim clearinghouse gathers the data from many of these claim files over a period of time and then creates a batch file including all these claims and transmits the file to a medical insurance company via a file transfer protocol. The medical insurance company processes these claims over a period of time, sometimes extending as long as months. A claim acknowledgement or payment response transactions are created and gathered together based on the submitting medical claim clearinghouse. A file containing the responses to the claims previously transmitted from the specific clearinghouse is transmitted back to the medical claim clearinghouse. The medical claim clearinghouse then splits the response file into various response files to enable transmitting claim responses back to the submitting physician office.
On the other hand, pharmacy claims submitted from pharmacy systems to pharmacy benefit manager systems for adjudication are processed in real time. Pharmacy systems create a single NCPDP claim request transaction and then connect to a pharmacy transaction switch entity and transmit the claim request to the switch. With the connection still open between the pharmacy system and the switch, the claim request transaction is routed and transmitted thereby to a Pharmacy Benefit Manager (PBM) that adjudicates the claim, creates a claim response with acceptance and payment information, and transmits the claim back to the switch. The switch then routes the claim response back to the submitting pharmacy using the still open connection. As a result, pharmacies can determine if a patient is eligible to receive a specific service, exactly how much the patient must pay for the service, and how much the pharmacy will be paid from the PBM within a few seconds.
A further problem is that medical billing systems and medical billing transaction standards are based on identifying products and their related services using a separate Current Procedure Terminology (CPT) code or Health Care Procedure Coding (HCPC) code for a drug product or other type of product being administered or dispensed, and an additional CPT or HCPC code for the related service of administering the drug or dispensing the product. Pharmacy insurance companies or pharmacy benefit managers use one National Drug Code (NDC) registered with the Food and Drug Administration (FDA) to identify both the product and the related service as one unit. An example is that pharmacy insurance companies or their pharmacy benefit managers identify the administration of a vaccine as one NDC code whereas a medical billing system would identify the vaccine product as one CPT code and the related administration service as a separate CPT code. The use of two different code sets for the identification of products and services creates additional barriers for medical providers to offer these pharmacy services and further restricts access for patients to the services.
Yet another problem is that pharmacy insurance company systems and PBMs use the prescription number as the primary identifier for a particular claim transaction, which consists of both the product and related administration fee for one drug. If there are two vaccines administered to a patient, then two prescription numbers are used to identify the claims. Medical Billing Systems do not generate prescription numbers at all, and use one Patient Control Number as the identifier for one claim that may contain multiple vaccine products and multiple administration fees. For example, when a PBM transmits an 835 remittance advice transaction, it uses the prescription number as the primary identifier for each claim consisting of one vaccine and one administration fee. If this 835 remittance advice transaction is received by a medical billing system, it will not know how to match the payments in the ERA to the initial submitted claims.
Accordingly, there is a need in the art for improved systems and methods for billing pharmacy insurance companies or their pharmacy benefit managers for services performed by medical providers and other non-pharmacy providers.